Seminars in Neurosurgery 2004; 15(2/03): 221-232
DOI: 10.1055/s-2004-835710
Copyright © 2004 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA.

Surgery in the Dorsal Root Entry Zone for Pain

Marc P. Sindou1 , Patrick Mertens1
  • 1Department of Neurosurgery, University of Lyon, Lyon, France
Further Information

Publication History

Publication Date:
25 October 2004 (online)

The dorsal root entry zone (and dorsal horn)-which is the first important level of modulation for pain sensation-can be a neurosurgical target to treat resistant pain. Lesioning techniques include microsurgical coagulation, radiofrequency thermocoagulation, laser beam or ultrasound lesion maker. Indications are (1) malignant pain in patients with long life expectancy and cancer that is limited in extent (such as in Pancoast-Tobias syndrome); (2) persistent neuropathic pain that is due to (a) brachial plexus injuries, especially those with avulsion, (b) spinal cord lesions (predominantly in the conus medullaris), especially the pain corresponding to segmental lesions (pain below the lesion is not favorably influenced), (c) segmental pain caused by lesions in the cauda equina, (d) peripheral nerve injuries, amputation, or herpes zoster, when the predominant component of pain is of the paroxysmal type and/or corresponds to provoked allodynia or hyperalgesia; and (3) disabling hyperspastic states with pain.

REFERENCES

  • 1 Gildenberg P. History of pain management. In: Greenblatt SH, Dagi TF, Epstein MH A History of Neurosurgery. Park Ridge, IL; American Association of Neurological Surgeons 1997: 429-464
  • 2 Melzach R, Wall P D. Pain mechanism. A new theory.  Science. 1965;  150 971-979
  • 3 Wall P D, Sweet W H. Temporary abolition of pain in man.  Science. 1967;  155 108-109
  • 4 Sindou M. Study of the Dorsal Root Entry Zone. Implications for Pain Surgery. M.D. thesis. Lyon; University of Lyon Press 1972
  • 5 Sindou M, Quoex C, Baleydier C. Fiber organization at the posterior spinal cord-rootlet junction in man.  J Comp Neurol. 1974;  153 15-26
  • 6 Nashold B S, Urban B, Zorub D S. Phantom pain relief by focal destruction of substantia gelatinosa of Rolando. In: Bonica JJ, Albe-Fessard D Advances in Pain Research and Therapy. Vol 1. New York; Raven Press 1976: 959-963
  • 7 Nashold B S, Ostdahl P H. Dorsal root entry zone lesions for pain relief.  J Neurosurg. 1979;  51 59-69
  • 8 Levy W J, Nutkiewicz A, Ditmore M, Watts C. Laser induced dorsal root entry zone lesions for pain control. Report of three cases.  J Neurosurg. 1983;  59 884-886
  • 9 Powers S K, Adams J E, Edwards S B, Boggan J E, Hosobuchi Y. Pain relief from dorsal root entry zone lesions made with argon and carbon dioxide microsurgical lasers.  J Neurosurg. 1984;  61 841-847
  • 10 Kandel E L, Ogleznev K JA, Dreval O N. Destruction of posterior root entry zone as a method for treating chronic pain in traumatic injury to the brachial plexus.  Vopr Neurochir. 1987;  6 20-27
  • 11 Dreval O N. Ultrasonic DREZ-operations for treatment of pain due to brachial plexus avulsion.  Acta Neurochir (Wien). 1993;  122 76-81
  • 12 Sindou M, Fischer G, Mansuy L. Posterior spinal rhizotomy and selective posterior rhizidiotomy. In: Krayenbühl H, Maspes PE, Sweet WH Progress in Neurological Surgery. Vol 7. Basel; Karger 1993: 201-250
  • 13 Sindou M, Goutelle A. Surgical posterior rhizotomies for the treatment of pain. In: Krayenbühl H Advances and Technical Standards in Neurosurgery. Vol. 10. Vienna; Springer-Verlag 1983: 147-185
  • 14 Rand R. Further observations on Lissauer's tractolysis.  Neurochirurgica. 1960;  3 151-168
  • 15 Denny-Brown D, Kirk E J, Yanagisawa N. The tract of Lissauer in relation to sensory transmission in the dorsal horn of spinal cord in the macaque monkey.  J Comp Neurol. 1973;  151 175-200
  • 16 Ramon y Cajal S. Histologie du Système Nerveux. Vol 1. Paris; Maloine 1901: 986
  • 17 Szentagothai J. Neuronal and synaptic arrangement in the substantia gelatinosa rolandi.  J Comp Neurol. 1964;  122 219-239
  • 18 Wall P D. Presynaptic control of impulses at the first central synapse in the cutaneous pathway. In: Eccles JC, Schadé JP Physiology of Spinal Neurons. Amsterdam; Elsevier 1964: 92-118
  • 19 Loeser J D, Ward Jr A A, White Jr L E. Chronic deafferentation of human spinal cord neurons.  J Neurosurg. 1968;  29 48-50
  • 20 Jeanmonod D, Sindou M, Magnin M, Baudet M. Intra-operative unit recordings in the human dorsal horn with a simplified floating microelectrode.  Electroencephalogr Clin Neurophysiol. 1989;  72 450-454
  • 21 Guenot M, Hupe J M, Mertens P, Ainsworth A, Bullier J, Sindou M. A new type of microelectrode for obtaining unitary recordings in the human spinal cord.  J Neurosurg. 1999;  91 25-32
  • 22 Guenot M, Bullier J, Rospars J, Lansky P, Mertens P, Sindou M. Single-unit analysis of the spinal dorsal horn in patients with neuropathic pain.  J Clin Neurophysiol. 2003;  20 143-150
  • 23 Loeser J D, Ward Jr A A. Some effects of deafferentation on neurons of the cat spinal cord.  Arch Neurol. 1967;  17 629-636
  • 24 Albe-Fessard D, Lombard M C. Use of an animal model to evaluate the origin of and protection against deafferentation pain. In: Bonica JJ Pain Research and Therapy Vol 5 New York; Raven Press 1983: 691-700
  • 25 Guenot M, Bullier J, Sindou M. Clinical and electrophysiological expression of deafferentation pain alleviated by dorsal root entry zone lesions in rats.  J Neurosurg. 2002;  97 1402-1409
  • 26 Sindou M, Fischer G, Goutelle A, Mansuy L. La radicellotomie postérieure sélective. Premiers résultats dans la chirurgie de la douleur.  Neurochirurgie. 1974;  20 391-408
  • 27 Sindou M, Fischer G, Goutelle A, Schott B, Mansuy L. La radicellotomie postérieure sélective dans le traitement des spasticités.  Rev Neurol. 1974;  130 201-215
  • 28 Jeanmonod D, Sindou M. Somatosensory function following dorsal root entry zone lesions in patients with neurogenic pain or spasticity.  J Neurosurg. 1991;  74 916-932
  • 29 Nashold B S. Personal Communication. 2001
  • 30 Jeanmonod D, Sindou M, Mauguière F. The human cervical and lumbo-sacral evoked electrospinogram. Data from intra-operative spinal cord surface recordings.  Electroencephalogr Clin Neurophysiol. 1991;  80 477-489
  • 31 Turano G, Sindou M, Mauguière F. SCEP monitoring during spinal surgery for pain and spasticity. In: Dimitrijevic MR, Halter JA Atlas of Human Spinal Cord Evoked Potentials. Boston; Butter worth-Heinemann 1995: 107-122
  • 32 Sindou M, Turano G, Pantieri R, Mertens P, Mauguière F. Intraoperative monitoring of spinal cord SEPs, during microsurgical DREZotomy (MDT) for pain, spasticity and hyperactive bladder.  Stereotact Funct Neurosurg. 1994;  62 164-170
  • 33 Mertens P, Ghaemmaghami C, Bert L et al.. Microdialysis study of amino-acid neurotransmitters in the spinal dorsal horn of patients undergoing microsurgical dorsal root entry zone lesioning.  J Neurosurg. 2001;  94 165-173
  • 34 Nashold B S. Modification of DREZ lesion technique (letter).  J Neurosurg. 1981;  55 1012
  • 35 Nashold J RB, Nashold D S. Microsurgical DREZotomy in treatment of deafferentation pain. In: Schmidek HH, Sweet WH Operative Neurosurgical Techniques. 3rd ed. Philadelphia; WB Saunders 1995: 1623-1636
  • 36 Levy W J, Gallo C, Watts C. Comparison of laser and radiofrequency dorsal root entry zone lesions in cats.  Neurosurgery. 1985;  16 327-330
  • 37 Nashold B S, Walker J S. Laser effect on spinal cord.  J Neurosurg. 1984;  60 870
  • 38 Young R F, Foley K, Chambi I V, Rand R W. A comparison of radiofrequency and laser techniques. Personal communication 1988
  • 39 Young R F. Clinical experience with radio-frequency and laser DREZ lesions.  J Neurosurg. 1990;  72 715-720
  • 40 Sindou M, Lapras C. Neurosurgical treatment of pain in the Pancoast-Tobias syndrome. Selective posterior rhizotomy and open antero-lateral C2-cordotomy. In Bonica JJ, Ventafrida V, Pagni CA Advances in Pain Research and Therapy. Vol 4. New York; Raven Press 1982: 199-209
  • 41 Emery E, Blondet E, Mertens P, Sindou M. Microsurgical DREZotomy for pain due to brachial plexus avulsion: long-term results in a series of 37 patients.  Stereotact Funct Neurosurg. 1997;  68 155-160
  • 42 Sindou M, Blondet E, Emery E, Mertens P. Microsurgical DREZotomy for pain due to brachial plexus avulsion: 1) intraoperative anatomical findings and 2) long-term results, in a series of 55 patients. Submitted for publication 2004
  • 43 Friedman A H, Nashold B S, Bronec P R. Dorsal root entry zone lesions for the treatment of brachial plexus avulsion injuries: a follow-up study.  Neurosurgery. 1988;  22 369-373
  • 44 Thomas D GT, Jones S T. Dorsal root entry zone lesions in brachial plexus avulsion.  Neurosurgery. 1984;  15 966-968
  • 45 Thomas D GT, Kitchen N D. Long-term follow-up of dorsal root entry zone lesions in brachial plexus avulsion.  J Neurol Neurosurg Psychiatry. 1994;  57 737-738
  • 46 Rath S A, Braun V, Soliman N, Antoniadis G, Richter M P. Results of DREZ-coagulations for pain related to plexus lesions, spinal cord injuries and post-herpetic neuralgia.  Acta Neurochir (Wien). 1996;  138 364-369
  • 47 Samii M, Bear-Henney S, Ludemann W, Tatagiba M, Blomer U. Treatment of refractory pain after brachial plexus avulsion with dorsal root entry zone lesions.  Neurosurgery. 2001;  48 1269-1277
  • 48 Sindou M, Daher A. Spinal cord ablation procedures for pain. In: Dubner A, Gebbart GF, Bond MR Proceedings of the Fifth World Congress on Pain. Amsterdam; Elsevier 1988: 477-495
  • 49 Nashold B S, Bullitt E. DREZ-lesions to control central pain in paraplegics.  J Neurosurg. 1981;  55 414-419
  • 50 Sampson J H, Cashman R E, Nashold B S, Friedman A H. Dorsal root entry zone lesions for intractable pain after lesions to the conus medullaris and cauda equina.  J Neurosurg. 1972;  37 412-417
  • 51 Sindou M. Microsurgical DREZotomy (MDT) for pain, spasticity and hyperactive bladder: a 20 year experience.  Acta Neurochir (Wien). 1995;  137 1-5
  • 52 Spaic M, Petkovic S, Tadic R, Minic L. Drez-surgery on conus medullaris (after failed implantation of vascular omental graft) for treating chronic pain due to spine (gunshot) injuries.  Acta Neurochir (Wien). 1999;  141 1309-1312
  • 53 Sindou M, Mertens P, Wael M. Microsurgical DREZotomy for pain due to spinal cord and/or cauda equina injuries. Long-term results in a series of 44 patients.  Pain. 2001;  92 159-171
  • 54 Friedman A H, Nashold B S, Ovelmen-Levitt J. Drez-lesions for the treatment of post-herpetic neuralgia.  J Neurosurg. 1984;  60 1258-1261
  • 55 Tsubokawa T, Katayama Y, Yamamoto T, Hirayama T, Koyama S. Chronic moteur cortex stimulation for the treatment of central pain.  Acta Neurochir Suppl (Wien). 1991;  52 137-139
  • 56 Mertens P, Nuti C, Sindou M et al.. Precentral cortex stimulation for the treatment of central neuropathic pain.  Stereotact Funct Neurosurg. 1999;  73 122-125
  • 57 Dubuisson D. Treatment of occipital neuralgia by partial posterior rhizotomy at C1-3.  J Neurosurg. 1995;  82 581-586
  • 58 Sindou M, Millet M F, Mortamais J, Eyssette M. Results of selective posterior rhizotomy in the treatment of painful and spastic paraplegia secondary to multiple sclerosis.  Appl Neurophysiol. 1982;  45 335-340
  • 59 Sindou M, Abdennebi B, Sharkey P. Microsurgical selective procedures in the peripheral nerves and the posterior root-spinal cord junction for spasticity.  Appl Neurophysiol. 1985;  48 97-104
  • 60 Sindou M, Mifsud J J, Boisson D, Goutelle A. Selective posterior rhizotomy in the dorsal root entry zone for treatment of hyperspasticity and pain in the hemiplegic upper limb.  Neurosurgery. 1986;  18 587-595
  • 61 Sindou M, Jeanmonod D. Microsurgical DREZ-tomy for the treatment of spasticity and pain in the lower limbs.  Neurosurgery. 1989;  24 655-670
  • 62 Sindou M, Jeanmonod D, Mertens P. Surgery in the DREZ: microsurgical DREZotomy for treatment of spasticity. In: Sindou M, Abbott R, Keravel Y Neurosurgery for Spasticity. Vienna; Springer Verlag 1991: 165-182
  • 63 Gybels J M, Tasker R R. Central neurosurgery. In: Wall PD, Melzach R Textbook of Pain. 4th ed. Edinburgh; Churchill-Livingston 1999: 1307-1338
  • 64 Sindou M, Mertens P, Garcia-Larrea L. Surgical procedures for neuropathic pain.  Neurosurgery Quarterly. 2001;  11 45-65
  • 65 Burchiel K J. Surgical Management of Pain. New-York; Thieme 2002

Marc P SindouM.D. D.Sc. 

Department of Neurosurgery, University Claude-Bernard, Hôpital Neurologique Pierre Wertheimer

59 Bd Pinel, 69003 Lyon, France

Email: marc.sindou@chu-lyon.fr

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